News from the International AIDS Conference

This edition concentrates on relevant research from the 20th
International AIDS Conference (AIDS 2014), held in Melbourne, Australia at the
end of July. For all our news reporting from the conference, visit www.aidsmap.com/aids2014

In San Francisco, both the estimated incidence (rate of new
infections) and recorded number of new diagnoses have been falling since 2007,
whereas these figures have either remained static or risen in London.

Why? The most obvious difference is in the proportion of gay
men who know their HIV status. Although around half of Londoners claim to have
tested recently (in surveys done on the gay scene), figures on the actual
number of tests done at GUM clinics would suggest that only 17% test each year.
Rates are much higher in San Francisco. San Francisco had a particularly sharp
drop in the proportion of gay men living with HIV who are undiagnosed, from 22
to 4% between 2004 and 2011.

In both cities, similar numbers of men report sex without
condoms. But higher testing rates in San Francisco apparently lead to higher
rates of HIV status disclosure between gay men and, as a result, much higher
rates of serosorting that is based on men’s actual HIV status (rather than
guesses). There was a falling rate of unprotected sex with partners of opposite
or unknown status in San Francisco compared with no change in London.

The analysis suggests that very high rates of
HIV testing, awareness, and disclosure of HIV status can play a critical role
in HIV prevention. But a culture of openness about HIV-positive status may be
more achievable in a city where one-in-four gay men are living with HIV. Can London
achieve San Francisco’s culture of testing and disclosure in a larger,
lower-prevalence population?

Drugs and sex

Although the finding will confirm many people’s common sense
beliefs, it has not previously been demonstrated in UK research. Previous
studies have found associations between men using drugs at least once in the
past few months and men having unprotected sex at least once during that period
– but have not analysed their interaction during a single event.

Whereas there was a 25% probability of unprotected sex when
no substances were used, this rose to 30% when one substance had been taken,
50% with three substances and a 75% probability of unprotected sex when more
than five substances had been taken.

Poppers, GHB and crystal methamphetamine were
the drugs most frequently associated with unprotected sex. But while men were
less likely to feel ‘in control’ of what they were doing if they had taken
crystal meth, other drugs were not
associated with feeling ‘out of control’. In other words, the link between drug
use and risky sex is more complex than drugs leading to men being unaware of
what they are doing sexually.

Related links

Treatment optimism

It is sometimes suggested that people who are taking HIV
treatment will be less worried about transmitting HIV and so less likely to use
condoms. This idea is known as ‘treatment optimism’ or ‘risk compensation’, and
is also a concern raised in relation to the use of pre-exposure prophylaxis (PrEP)
by HIV-negative people.

In fact, the analysis consistently found that people who
were taking treatment were more likely
to use condoms than people who were not. Treatment was associated with an
increased likelihood of consistent condom use (odds ratio 1.8) and of using a condom
the last time a person had sex (odds ratio 2.3).

This was the case for both men and women; for committed
relationships and casual sex; and for partners both known, and not known, to be
HIV negative.

The results may suggest that instead of
‘treatment optimism’ causing complacency, the provision of HIV treatment could
lead to decreased HIV risk behaviour due to regular medical contact and
counselling, as well as being linked with an increased hope for the future and a
sense of agency. The researchers said that the findings show that the phrase
‘treatment as prevention’ may be true in more ways than one.

Couples counselling and testing

The intervention involves couples being counselled together,
taking HIV tests together, and being counselled together on the implications of
the results, whatever they are, afterwards. The process aims to reduce tension,
diffuse blame, and create an environment in which HIV status can be disclosed
safely.

Approximately 150,000 couples have received couples testing
in Lusaka, Zambia. Previous surveillance in Zambia had shown that in couples of
differing HIV status, annual HIV incidence in the HIV-negative partner was 11%
(i.e. one in nine acquired HIV per year). But after couples testing, incidence
dropped to 2% a year (i.e. one in 50 of the HIV-negative partners acquired HIV
a year) – an 82% decline in incidence.

A similar decline in incidence was observed in couples who
were both HIV negative.

For couples in which one person was living with HIV, the
couples counselling and testing appeared to help people take and adhere to HIV
treatment – probably by promoting disclosure of HIV status and encouraging
partners to support each other with adherence. In couples where HIV status had
not been disclosed, adherence was quite poor.

A case study in a previous
edition of this bulletin reported on LASS’ experience of couples testing in
Leicester, but in general it is not an approach that has been sufficiently
explored in the UK.

PrEP

The study compared infection rates among individuals
taking PrEP and individuals who chose not to take it. It provides the first effectiveness
results from a large, open-label study of PrEP where participants knew they
were not taking a placebo.

A total of 1603 men who have sex with men (MSM) and
transgender women were recruited to the study, 1225 of whom chose to take PrEP.

Participants were followed for up to 72 weeks. Overall,
taking PrEP reduced the risk of acquiring HIV by half. But the effectiveness of
the treatment was related to adherence.

The treatment had no impact on the risk of infection for
participants who took fewer than two doses a week. For participants who took
two to three weekly doses, the treatment reduced the risk of acquiring HIV by
84%. No HIV infections were seen in the sub-group who took four or more doses a
week. But only a third of participants managed such a high level of adherence.

Adherence was strongly associated with age: study
participants in their 30s and 40s were two or three times more likely to have
detectable levels of PrEP drugs in their blood compared to younger people.

The researchers also calculated that only 39% of
participants at high risk of HIV at the start of the study were taking enough
PrEP doses to protect them against HIV three months later. The number of people
who were not motivated enough to take PrEP consistently may show that PrEP is
not a practical option for some people who are at risk, or that more
sophisticated support is needed.

Early
data from a French study of PrEP suggest that four-in-five participants
were taking the drugs at least some of the time. In this trial gay men are only
asked to take the drugs before and after having sex.

It’s not clear how self-testing will be made available, but
WHO have begun to scope out some of the possibilities:

Open-access
and unsupervised, with sales or distribution through retail pharmacies,
websites or vending machines (the dominant model in the United States).

Some
restrictions on access, with tests available from outreach workers,
pharmacists or clinicians. Eligibility criteria might be more or less
strict, depending on national policies and the epidemiological context.

Supervised
self-testing, with additional support from a health worker or community
volunteer, such as a demonstration of how to use the test or referrals to
additional services.

At present there is only one self-test kit that
has been licensed by a respected regulatory body and is commercially available
(the OraQuick test in the United
States). But there are considerable challenges to bringing new self-test kits
to the market. From the point of view of a commercial manufacturer or
distributor, there are many uncertainties and therefore few incentives to be
the first company to launch a product. The size of the market is difficult to
estimate, efficient distribution systems do not yet exist, national HIV
programmes haven’t defined the role of self-testing, and regulatory
processes are often unclear or complex.

NAT also argue that there is a lack of robust and
independent evaluation of prevention work, which hinders the development of a
shared knowledge-base of which interventions work and of the ways in which they
work.

They report that a recurring theme among the stakeholders
they consulted was the dislike of HIV prevention activity which singles black
African people out as the one ethnic group amongst heterosexual people who are
at risk of HIV. The question of “targeting” must be sensitively handled, they
believe, suggesting that interventions which reach black African people should
be integrated with wider work for the sexually active heterosexual population.

NAT’s report also criticises the failure of primary care and
other NHS services to implement guidelines on HIV testing. As a result, rates
of late diagnosis remain considerably higher in African people than in other
communities.

Other recent news headlines

If there was a phrase that defined the 20th International AIDS Conference (AIDS 2014), one that surfaced in every few presentations and kept turning up in documents, it was “key affected populations”. Read more >>

There are significant losses at each step of the post-exposure prophylaxis (PEP) ‘treatment cascade’, according to a systematic review and meta-analysis of 97 studies presented to the 20th International AIDS Conference. The problems with uptake, adherence and completion point to a need for a simplified approach, comment the authors. Read more >>

Editors' picks from other sources

A few months ago, the CDC recommended Truvada, the HIV prevention pill, to anyone at risk of infection. The Verge and other media outlets – including The New York Times, The Washington Post, and Slate – covered the news in a big way, because it meant that government officials were not only urging doctors to prescribe the drug to queer men or individuals whose partners have HIV, but to anyone at risk – including sex workers, heterosexuals, and transfolk. Yet many reporters, myself included, failed to discuss how revolutionary this drug is for one particular, and substantial, segment of the US population: women.

from HIV Vaccines and Microbicides Resource Tracking Working Group press release

Investment
in HIV prevention research fell US$50 million, or 4%, to US$1.26
billion in 2013, due to declining investments by the United States and
European government donors, changes in the international development
landscape and changes in the pipeline of HIV prevention products in
various stages of development and implementation, according to a new
report from the HIV Vaccines and Microbicides Resource Tracking Working
Group.

London Friend has published a report examining how drug and
alcohol treatment services can be improved for lesbian, gay, bisexual and trans
people. It includes a description of different models of service delivery, as
well as the opinions of service users and commissioners. The report can be viewed here.

The National Institute for Health and Care Excellence (NICE)
has prepared a briefing to help local authorities make sure that HIV testing
and prevention in their area is tailored to local needs. It
can be read here.

National HIV Testing Week

National HIV Testing Week will take place between 22nd and 30th November 2014.

NAM is an award-winning, community-based organisation, which works from the UK. We deliver reliable and accurate HIV information across the world to HIV-positive people and to the professionals who treat, support and care for them.